Table 1.

Core components of the ACP intervention

I. Negotiate an agenda for the consultation

II. Assess the patient’s and/or family’s readiness to discuss future care

III. Establish the patients’ preferred substitute decision maker(s)

IV. Explore the patients understanding of their medical situation, any unmet information needs and provide information if appropriate

V. Ask the patient for permission to discuss prognosis

If they wish to hear further information progress with providing best, worst and most likely scenarios.

VI. Explore the patient’s values, goals, priorities, hopes, fears and concerns for the future

E.g. When you look at the future: what do you hope for? What worries you?

What is most important to you? What makes your life worth living?

If you were to become more unwell in the future:

What would be most important to you?

How would like to be cared for?

Is there anything else we should know about your wishes?

VII. Explore if there are any situations, treatments or health states the patient would find unacceptable

E.g. Is there anything that you worry about happening?

What is the worst medical outcome for you, that you still feel would give you quality of life?

Can you think of any circumstances where you would prefer the focus of treatment to be on comfort rather than extending life?

VIII. Summarise your understanding of the person’s most important wishes for future care

IX. Consider any other specific treatment options relevant to the person’s circumstances

Consider medical interventions such as: ICU admissions, invasive mechanical ventilation, non-invasive ventilation, IV fluids and antibiotics, chemotherapy (discuss treatment intent)

X. Consider offering to make a recommendation for future medical care, if they were to become too sick to speak for themselves, based on their values and wishes

XI. Help the patient to document their wishes